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An Immediate Jeopardy (IJ) situation was identified during the survey at A115 Patient Rights. On September 21, 2022 at 4:21 PM, the Chief Nursing Officer of UF Health Shands Hospital, an affiliated hospital, was informed of the determination of immediate jeopardy and given the immediate jeopardy templates.

The immediate jeopardy began on September 3, 2022, when the facility failed to keep Patient #1 free from neglect when Patient #1 did not have every 15-minute monitoring and checks to ensure patient safety and failed to assess vital signs per physician order according to current accepted professional standards of practice. The patient was found unresponsive and absent of vital signs. The patient did not survive.

The facility failed to ensure Patient rights were honored for care in a safe setting for 1 of 3 patients, Patient #1. The hospital failed to follow current acceptable standards of practice when every 15-minute monitoring observations were not completed as ordered per policy and failed to assess vital signs per physician order, resulting in the patient being left in an unsafe situation while in the hospital setting. This systemic failure constitutes an immediate jeopardy.

UF Health Psychiatric Hospital was not in compliance with Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals for 42 CFR 482.13 Patient Rights.

Refer to A 144- Patient Rights- Care in a safe setting.

Based on video review, medical record review, interview, and policy and procedure review the facility failed to ensure patient rights were honored for care in a safe setting for 1 of 3 patients, Patient #1, when the facility did not follow current accepted professional standards of practice to provide every 15-minute checks and assess for vital signs as order by the physician for 1 of 3 patients, Patient #1. The patient was found unresponsive and absent of vital signs. Patient #1 did not survive.

Findings include:

Review of the Medical record reads, "Patient #1 was a 34-year-old male who presented to the psychiatric hospital intake voluntarily on 8/29/2022. Review of the History and physical dated 8/30/2022 reads, "CC [chief complaint]: I need help to stop using benzodiazepines and opioids. HPI [History of presenting illness]: 34 y.o. [year old] married WM [white male] from Alabama with no significant medical history presents voluntarily for medical management of benzodiazepine [a medication used for anxiety] and opioid [a class of drugs used to treat pain] withdrawal. He reports using clonazepam [a benzodiazepine used to treat seizures and anxiety] 4 milligrams per day and Xanax [a benzodiazepine used to treat anxiety and panic disorder] up to 30 milligrams per day (last use 8/28), hydrocodone [a pain medication] up to 150 milligrams per day (last use 8/25). He is also prescribed Adderall IR [a medication used to treat attention deficit hyperactivity disorder], which he uses as prescribed, 30 milligrams q.a.m. [every morning] and 20 milligrams q.p.m. [every evening] and testosterone (biweekly injections). He is made several unsuccessful attempts to discontinue the benzodiazepines and experienced at least 6 seizures after he stops taking them. He is also made several unsuccessful attempts to stop the opioids. He reports spending proximally 1000 dollars per week on substances. His wife is aware of his use and it caused conflict in his marriage. However, she is supportive in his efforts to attend treatment. He obtains Xanax and hydrocodone illicitly, although he is certain it is pharmaceutical grade. Approximate 2 months ago he attempted treatment at [Facility name] in Alabama but left after 3 days. Was on buprenorphine [a medication used to treat opiate use disorder] for approximately 2 months about 5 years ago.

Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He appears to be experiencing withdrawal symptoms, most likely related to opioids, including chills, sweating and diarrhea. Symptoms are adequately controlled with diazepam and buprenorphine. Dimension 2: Biomedical conditions and complications: None identified. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild depression/anxiety. Dimension 4: Readiness to change: The patient has both cognitive and emotional awareness of his disease. He appears to be generally internally motivated. Dimension 5: Relapse/continued use potential: He is at very high risk for continued use without treatment in a structured environment. Dimension 6: Recovery environment: He lives with his wife (who is supportive) and 3-year-old daughter. Diagnosis: Principal Problem: Sedative, hypnotic or anxiolytic use disorder, severe, dependence. Active Problems: Opioid use disorder, severe, dependence, Unspecified stimulant related disorder and Unspecified androgenic steroid related disorder. Plan: Admit to [Hospital name], Dual Disorders Unit, for inpatient detoxification/stabilization/assessment. Complete laboratory workup to include testosterone level. Obtain collateral information. Pharmacologic management of benzodiazepine and opioid withdrawal."

Review of Benzodiazepine and Opiate withdrawal symptoms include sleepless, anxiety, depression, sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, difficulty in concentration, dry wrenching and nausea, some weight loss, palpitations, headache, muscular pain and stiffness and a host of perceptual changes. Instances are also reported within the high-dosage category of more serious developments such as seizures and psychotic reactions. Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns. The most common is a short-lived "rebound" anxiety and insomnia, coming on within 1-4 days of discontinuation, depending on the half-life of the particular drug. The second pattern is the full-blown withdrawal syndrome, usually lasting 10-14 days; finally, a third pattern may represent the return of anxiety symptoms which then persist until some form of treatment is instituted. Withdrawal phenomena appear to be more severe following withdrawal from high doses of short-acting benzodiazepines. Patient #1 was being administered Valium 15 milligrams and Subutex 4 milligrams. Using buprenorphine (Subutex and Klonopin) together with other medications that also cause central nervous system depression (Valium) can lead to serious side effects such as respiratory distress, coma, and even death.

Review of nursing progress note dated 8/29/2022 at 9:55 PM reads, "Pt [patient] anxious, cooperative, during admission interview. Pt c/o [complain of] "brain zaps, restlessness, diarrhea, and anxiety; patient's forehead appeared moist. Valium, Imodium, and clonidine given. Pt reports that the valium and clonidine did not alleviate his symptoms. [Doctors name] notified. Pt endorses depression but denies SI/HI/AVH [suicidal ideations/homicidal ideations/audio visual hallucinations]. CIWA [Clinical Institute Withdrawal Assessment from Alcohol] 12, COWS [Clinical Opiate Withdrawal Scale] 9."

Review of nursing progress note dated 8/30/2022 at 4:39 PM reads, "[Patient #1's name] is calm, cooperative, and withdrawn to his room with the exception of meals and snacks. Upon 1:1 assessment the denies pain or any other somatic complaints. [Patient #1's name] reports poor sleep with a fair appetite and he describes his mood as "Better". Patient denies current depression and rates his anxiety level 4/10. [Patient #1's name] denies SI/HI/SIB[serious injurious behavior]/AVH. Will continue to monitor for safety as per care plan. CIWA [a 10 item scale used in the assessment and management of withdrawal symptoms] 7, COW [an 11 item scale used in the assessment of opiate withdrawal] 6." BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal].

Review of the physician progress note dated 8/31/2022 reads, "[Patient #1's name] is a 34 y.o. [year old] male admitted for problems related to benzodiazepines (reportedly uses on average Klonopin 4 mg [milligrams]/d [day] and Xanax 24 mg/d), opioids (hydrocodone, oxycodone, 10-15 pills/d), and Adderall 50 mg/d. Interval History: Today, patient reports insomnia, sweats, headache, twitching. He was tremulous on exam. He is willing to go to [Facility name] PHP [partial hospitalization program] after this. Signs of substance withdrawal: yes, Appetite: fair, Sleep: poor. Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Overall, symptoms have been adequately controlled with diazepam/gabapentin for sedative withdrawal, and buprenorphine for opioid withdrawal. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild anxiety of a generalized nature, and purported history of ADHD [attention deficit hyperactivity disorder] dx'd [diagnosed] in college. Benzodiazepines and stimulants should not be a part of his long-term treatment plan. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID [twice a day] (will keep valium PRN [as needed] available for now) Gabapentin as sedative withdrawal adjunct and seizure prevention, BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal], Plan for transition to [Facility name] PHP as soon as clinically appropriate."

Review of the physician progress note dated 9/1/2022 reads, "Interval History: Today, patient reports "unbearable headache" and "bad muscle tightness all over." Nauseated. Clenching his jaw. Feels twitchy at times. Slight tremor at times. No oversedation with medication. Has been taking PRN valium on top of the scheduled clonazepam. No SI/HI/AVH. His roommate is quite bothersome. Signs of substance withdrawal: yes, Appetite: poor, Sleep: poor. Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Sedative w/d [withdrawal] symptoms sub optimally controlled with diazepam /gabapentin. Buprenorphine has been helpful for opioid withdrawal. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID (will keep valium PRN available for now). Increase gabapentin dose today (sedative withdrawal adjunct and seizure prevention). Schedule muscle relaxer Ibuprofen for H/A [headache], BUP for OUD, Monitor Vital signs."

Review of Nursing progress note dated 9/1/2022 at 11:32 AM reads, "Pt medication compliant and up for breakfast. Withdrawn to room all morning c/o severe headache unrelieved by
Tylenol. [Medical Doctor's name] notified and 1x dose Ibuprofen 800 mg given. [Patient #1's name] reports relief. Pt also received PRN Valium for CIWA 12 after receiving Klonopin and Subutex approximately 1 hour apart. COWS 9. [Patient #1's name] thankful after being moved to private room where he will be able to rest more comfortably. [Patient #1's name] is pleasant but appears anxious with a constricted affect. Presents with a linear and logical thought process. Denies SI/SIB/HI/AVH. No morning group attended."

Review of physician progress note dated 9/2/2022 reads, "Interval History: Today, patient reports feeling "better than yesterday, better than yesterday." Sleep still not great. Negligible hand tremors. Appetite fair. Headaches continue to be annoying - relieved somewhat by the ibuprofen etc. He appreciated getting moved to a single room yesterday, as his roommate was quite bothersome. He appreciates the medication changes made yesterday. No oversedation with the current meds. Pulse and BP [blood pressure] still elevated at times. When discussing testosterone result, he admits taking a "double dose" just before coming here. Signs of substance withdrawal: yes Appetite: fair. Sleep: poor to fair. Plan: Continue inpatient level of care.
Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg
BID (will keep valium PRN available for now, today valium dose will reduce to 5 BID PRN and valium will be stopped altogether within 24). Continue gabapentin (sedative withdrawal adjunct and seizure prevention). Continue muscle relaxer methocarbamol Ibuprofen for H/A BUP for OUD Monitor Vital signs 12 Step Therapy for addiction Monitor for signs/symptoms of acute w/d, watch for oversedation Plan for transition to [Facility name] PHP when clinically appropriate. I certify that this patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel."

Review of the nursing progress note dated 9/2/2022 at 11:00 AM reads, "Patient pleasant, cooperative and medicine compliant. Patient reported "getting better" today, headache is
manageable. Patient denied SI, SIB, HI, AVH and depression. Patient endorsed having anxiety 7/10, c/o nausea - Zofran given with positive effect. CIWA 7, COWS 7, on scheduled Subutex and Clonopin [sp]. Patient given prn dose of Valium 5 mg po [by mouth] at 10:51am. Patient did not attend the morning group session. Patient interactive with some peers."

Review of the medication administration record documents that Subutex 4 mg SL (sublingual) was administered at 21:12 (9:12 PM) on 9/2/2022.

Review of the nursing progress note dated 9/3/2022 at 12:16 AM reads, "On approach, patient is resting in bed. He is pleasant and cooperative. Reports mood as "better." Denies SI/HI/AVH.
CIWA 5. COW 6. Med compliant."

Review of the nursing progress note dated 9/3/2022 at 1336 (1:36 PM) reads, "Patient found unresponsive in room this morning upon attempt to administer morning medications and assess pt. Code called and CPR [cardiopulmonary resuscitation] with AED [automated external defibrillator] initiated. 911 called. Pt unable to be revived."

Review of a physician progress note dated 9/3/2022 at 1358 (1:58 PM) reads, "Prior to our seeing the patient this morning on rounds, he was found unresponsive and code with CPR was initiated. Code was managed by psychiatry resident and by staff individual [ Doctors name]. EMS [emergency medical services] arrived on scene. Patient unable to be revived. Efforts were discontinued at approximately 10:00 a.m."

Review of the medical record, there was no code blue documentation within the medical record.

During an interview on 9/21/2022 at 1:00 PM the Risk Manager stated, "We immediately began to investigate what happened and set up a RCA [root cause analysis] and talk about it, we did individual interviews, and reviewed the medical record. We determined that every 15-minute checks were not completed as documented in the record for 9/2-3/2022. After 7:47 AM there were no additional 15-minute checks completed. We also identified that there was some education for reacting to a code. The patient was not seen by staff at shift change, and routine checks were not completed. Vital signs were not completed at 6:00 AM, the quality of the checks based on the video reviewed were not consistent with our policies and procedures. We identified that the code cart was not fully equipped with suction available. We did have the systems in place, but the staff did not follow them as expected. Based on the documentation the patient was last seen at about 12:15 AM, there is documentation in the chart."

During a telephone interview on 9/21/2022 at 6:10 PM Staff A, Mental Health Technician (MHT) stated, "I was on the day that he died [Patient #1]. I did not see him at all that day. I saw him in bed when I told him that breakfast was ready, on the unit. I really thought that I did his hourly rounding. I was just confused about what I was supposed to do and what the other tech was supposed to do. I did not do any bedside report we don't do that. I have not talked to anyone, not that day or since. I did not do bedside rounds, when I saw patients, it was from the doorway. I should have gone into the room."

During an interview on 9/22/2022 at 6:35 AM Staff B, Registered Nurse (RN) stated, "I did take care of him [Patient #1] overnight before he died. The last time I saw him and spoke with him was about 12:15 AM and I saw him once more at about 3:30 in the morning, I think. He was in bed laying on his left side and snoring. So, during my initial contact with the patient [Patient #1] he was ambulatory, he said his mood was better, he looked better, was articulate, looked neat and I didn't see any withdrawal symptoms. I was not at all concerned, and the patient did not express concerns. I did not do any 15-minute checks and I don't have any responsibility to round on the patients hourly or every two hours. I did not do bedside report with the nurse that came on shift. We don't do that with our patients, we never have. I guess we should check on them together, but sleep can be a problem for our patients, they don't sleep very well so if they were asleep, I wouldn't wake them up. I don't go behind the techs to see if they are doing their work, but I am supposed to see that the checks are documented. I check that they have documented them like they should."

During an interview on 9/22/2022 at 7:00 AM Staff C, RN stated, "The role of the MHT is to do every 15-minute checks, that has always included checking respirations. The MHT on that day is not someone that I felt I needed to watch or monitor. We are not required to complete rounding on the patients hourly or every two hours. We do a patient assessment, and if they come up to us complaining of withdrawal symptoms. Seizure precautions mean they are at risk for developing seizures because of history or what they are detoxing from. I was going into his room to give morning meds. I found him on his left side, looked like he was sleeping. When I walked in the room, he was purple, stiff, and cool to touch. I hurried to the nurses' station when I found him and immediately called the code and began that process. I actually never went back into the room again; I called the code and 911. Two other nurses responded to the room and administered CPR and got the code cart."

During an interview on 9/22/2022 at 9:30 AM Staff D, RN stated, "His nurse was [Nurse's name], she went into the room and when she came out, she quietly said, "he is blue." She called the code and when I went into the room, I saw he was blue, he looked swollen, his mouth was disfigured, like his teeth were clenched, he was blue and cold to the touch. I ran and got the cart, and I called Code blue. [Medical Doctor's name] pulled him onto the floor, and we began CPR. But we could not get him back, but I think he had been dead for a while."

Review of the facility video for 9/2/2022 beginning at 9:17 PM with the Risk Manager showed the camera angle of the West Day room allows a view of the common area and entrance to three rooms. The entrance to two rooms, including the room of the deceased, cannot be viewed due to the presence of a large column. 9/2/2022 at 9:17:31 PM Patient #1 is observed walking, coming from around the column exiting the room. On 9/2/2022 at 9:28:32 PM Patient #1 is seen going behind the column entering the room. On 9/3/2022 at 12:12 AM a MHT is observed checking two rooms and going behind the column. Checks consisted of cracking the door open, and looking in. The MHT did not enter the observed rooms. On 9/3/2022 there was no video observing the nurse's interaction with Patient #1 at 12:16 a. m. through continuous video viewing until 1:15 AM. On 9/3/2022 at 7:37 AM MHT rises from sitting at the desk and walks out of camera frame toward the area of the assigned rooms. On 9/3/2022 at 7:38 AM the MHT reappears in the camera frame and goes behind the column, presumably to check the rooms not visible by video. On 9/3/2022 at 7:43 AM the MHT is observed chatting with the nurse from another unit. On 9/3/2022 at 7:47 AM the MHT is observed walking around the column. Breakfast trays are seen delivered to the ward. Staff are observed serving breakfast. Eight patients were seated at the table and eating breakfast. On 9/3/2022 at 8:19 AM the MHT is observed checking rooms next to Patient #1's room but did not go behind the column to check rooms. On 9/3/2022 at 9:40 AM and 19 seconds the nurse is seen going behind the column with a small cup in her hand. At 9:40 and 38 seconds, the nurse comes from around the column appearing to be in a rush and speaks to the MHT. On 9/3/2022 at 9:41 AM the Physician who was on the ward making rounds enters the room of Patient #1 and at 9:42 AM the code cart arrives. Nurses and staff are observed entering the room. Video viewing ended.

During an interview on 9/22/2022 at 9:35 AM, the Risk Manager stated, "We had two MHT's on that day. Only one that previous night. I reviewed the video. The quality of the 15-minute checks is not up to our standards. Well, they were just not, they were just looking into the rooms. Not even going into the rooms. They did not verify that the patients were breathing and not having a medical emergency. They did not verify that they were not having seizures. Our seizure precautions are not clearly defined for this area. We can't have side rails so we can't pad them. Nurses should be making sure that the MHT are doing the checks. They just can't verify that they are doing them by looking at the charting, because in this case the documentation was not correct. This was inaccurate, false documentation. There were no checks completed at 5:30, 6:00, 6:22 when the MHT documented the patient refused vitals. The tape shows that he didn't attempt vitals. The day [Staff A's name], did not attempt to complete every 15-minute checks from 7:48- 9:40 AM but documented that every 15-minute checks where completed. The nurse did not do any checks during that time. The nurses did not do bedside rounds for shift report. We should have been doing the rounds and completing them with more than opening a door and verifying the patients were in bed. We did not see this patient at all between 7:47 and 9:40 AM. It is our policy to monitor patients every 15 minutes, to verify they are okay. They should have verified the patient was breathing on the rounds. There is a nurses note that the patient had contact at 12:18 AM, there is no video to document that this occurred. The last time the patient was seen on video was the evening before."

During an interview conducted on 9/22/2022 at 10:30 AM, the Interim Director of Nursing stated, "I was placed in the position after the director of nursing went on leave. I came into the position three days ago. I have not acted on the plan of correction. I have not done training or education with the staff. There were missing checks that were documented. We have not spoken to the MHT that was on that day yet. But the patient [Patient #1] was not checked every 15 minutes, the video was reviewed, and they were not completed. They should have been. There is no documentation related to the code, there should be."

Review of the Policy and Procedure titled, "Patient Levels of Observation" Policy Number SPH02. 038 reads, "Policy: Patients admitted to UF Health Shands Psychiatric Hospital will be observed for patient safety. Some patients may require an increased level of observation due to the acuity of their mental illness. Purpose: to provide reasonable safety for patients and staff members and to promote a therapeutic environment. Procedures: 1. Patient observation levels at UF Health Shands Psychiatric Hospital include: A. Routine. B. One-to-one. II. All patients are minimally placed on routine observation period in the event the patient requires one to one observation, this will be communicated during handoff and in the epic unit manager." III. In the event of a significant change in a patient's condition, the RN can increase the observation level to one to one and then contact the physician for the order. IV. Only a physician can order a decrease in observation level. Routine Observation: each patient on routine observations is observed by a staff member approximately every 15 minutes."

An Immediate Jeopardy (IJ) situation was identified during the survey at A263 QAPI (Quality Assurance Performance Improvement). On September 21, 2022, at 4:21 PM. The Chief Nursing Officer of UF Health Shands Hospital, an affiliated hospital, was informed of the determination of immediate jeopardy and given the immediate jeopardy templates.

The immediate jeopardy began on September 3, 2022, when the facility failed to keep Patient #1 free from neglect for failure to provide care according to current accepted professional standards of practice when Patient #1 did not have every 15-minute monitoring and checks to ensure patient safety and failed to complete vital signs as ordered by the physician. The patient was found unresponsive and absent of vital signs. The patient did not survive.

The hospital failed to ensure an effective and acceptable plan of correction was developed and implemented for a high risk and problem prone area when the facility failed to ensure actions were taken to safeguard the health outcome and safety of all patients by not performing every 15-minute observations and assess vital signs per the physician orders, this systemic failure constitutes an immediate jeopardy.

UF Health Psychiatric Hospital was not in compliance with Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals for 42 CFR 482.21 Quality Assessment and Program Improvement (QAPI).

Refer to A 0283- Quality Improvement Activities.

Based on video review, interview, and record review the facility failed to ensure an effective and acceptable plan of correction was developed and implemented to honor patient rights, and prevent neglect for not providing every 15-minute observations and physician ordered vital signs for 1 of 3 patients, Patient #1. The patient was found unresponsive and absent of vital signs. Patient #1 did not survive.

Findings include:

Review of the Medical record reads, "Patient #1 was a 34-year-old male who presented to the psychiatric hospital intake voluntarily on 8/29/2022. Review of the History and physical dated 8/30/2022 reads, "CC [chief complaint]: I need help to stop using benzodiazepines and opioids. HPI [History of presenting illness]: 34 y.o. [year old] married WM [white male] from Alabama with no significant medical history presents voluntarily for medical management of benzodiazepine [a medication used for anxiety] and opioid [a class of drugs used to treat pain] withdrawal. He reports using clonazepam [a benzodiazepine used to treat seizures and anxiety] 4 milligrams per day and Xanax [a benzodiazepine used to treat anxiety and panic disorder] up to 30 milligrams per day (last use 8/28), hydrocodone [a pain medication] up to 150 milligrams per day (last use 8/25). He is also prescribed Adderall IR [a medication used to treat attention deficit hyperactivity disorder], which he uses as prescribed, 30 milligrams q.a.m. [every morning] and 20 milligrams q.p.m. [every evening] and testosterone (biweekly injections). He is made several unsuccessful attempts to discontinue the benzodiazepines and experienced at least 6 seizures after he stops taking them. He is also made several unsuccessful attempts to stop the opioids. He reports spending proximally 1000 dollars per week on substances. His wife is aware of his use and it caused conflict in his marriage. However, she is supportive in his efforts to attend treatment. He obtains Xanax and hydrocodone illicitly, although he is certain it is pharmaceutical grade. Approximate 2 months ago he attempted treatment at [Facility name] in Alabama but left after 3 days. Was on buprenorphine [a medication used to treat opiate use disorder] for approximately 2 months about 5 years ago.

Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He appears to be experiencing withdrawal symptoms, most likely related to opioids, including chills, sweating and diarrhea. Symptoms are adequately controlled with diazepam and buprenorphine. Dimension 2: Biomedical conditions and complications: None identified. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild depression/anxiety. Dimension 4: Readiness to change: The patient has both cognitive and emotional awareness of his disease. He appears to be generally internally motivated. Dimension 5: Relapse/continued use potential: He is at very high risk for continued use without treatment in a structured environment. Dimension 6: Recovery environment: He lives with his wife (who is supportive) and 3-year-old daughter. Diagnosis: Principal Problem: Sedative, hypnotic or anxiolytic use disorder, severe, dependence. Active Problems: Opioid use disorder, severe, dependence, Unspecified stimulant related disorder and Unspecified androgenic steroid related disorder. Plan: Admit to [Hospital name], Dual Disorders Unit, for inpatient detoxification/stabilization/assessment. Complete laboratory workup to include testosterone level. Obtain collateral information. Pharmacologic management of benzodiazepine and opioid withdrawal."

Review of Benzodiazepine and Opiate withdrawal symptoms include sleepless, anxiety, depression, sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, difficulty in concentration, dry wrenching and nausea, some weight loss, palpitations, headache, muscular pain and stiffness and a host of perceptual changes. Instances are also reported within the high-dosage category of more serious developments such as seizures and psychotic reactions. Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns. The most common is a short-lived "rebound" anxiety and insomnia, coming on within 1-4 days of discontinuation, depending on the half-life of the particular drug. The second pattern is the full-blown withdrawal syndrome, usually lasting 10-14 days; finally, a third pattern may represent the return of anxiety symptoms which then persist until some form of treatment is instituted. Withdrawal phenomena appear to be more severe following withdrawal from high doses of short-acting benzodiazepines. Patient #1 was being administered Valium 15 milligrams and Subutex 4 milligrams. Using buprenorphine (Subutex and Klonopin) together with other medications that also cause central nervous system depression (Valium) can lead to serious side effects such as respiratory distress, coma, and even death.

Review of nursing progress note dated 8/29/2022 at 9:55 PM reads, "Pt [patient] anxious, cooperative, during admission interview. Pt c/o [complain of] "brain zaps, restlessness, diarrhea, and anxiety; patient's forehead appeared moist. Valium, Imodium, and clonidine given. Pt reports that the valium and clonidine did not alleviate his symptoms. [Doctors name] notified. Pt endorses depression but denies SI/HI/AVH [suicidal ideations/homicidal ideations/audio visual hallucinations]. CIWA [Clinical Institute Withdrawal Assessment from Alcohol] 12, COWS [Clinical Opiate Withdrawal Scale] 9."

Review of nursing progress note dated 8/30/2022 at 4:39 PM reads, "[Patient #1's name] is calm, cooperative, and withdrawn to his room with the exception of meals and snacks. Upon 1:1 assessment the denies pain or any other somatic complaints. [Patient #1's name] reports poor sleep with a fair appetite and he describes his mood as "Better". Patient denies current depression and rates his anxiety level 4/10. [Patient #1's name] denies SI/HI/SIB[serious injurious behavior]/AVH. Will continue to monitor for safety as per care plan. CIWA [a 10 item scale used in the assessment and management of withdrawal symptoms] 7, COW [an 11 item scale used in the assessment of opiate withdrawal] 6." BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal].

Review of the physician progress note dated 8/31/2022 reads, "[Patient #1's name] is a 34 y.o. [year old] male admitted for problems related to benzodiazepines (reportedly uses on average Klonopin 4 mg [milligrams]/d [day] and Xanax 24 mg/d), opioids (hydrocodone, oxycodone, 10-15 pills/d), and Adderall 50 mg/d. Interval History: Today, patient reports insomnia, sweats, headache, twitching. He was tremulous on exam. He is willing to go to [Facility name] PHP [partial hospitalization program] after this. Signs of substance withdrawal: yes, Appetite: fair, Sleep: poor. Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Overall, symptoms have been adequately controlled with diazepam/gabapentin for sedative withdrawal, and buprenorphine for opioid withdrawal. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild anxiety of a generalized nature, and purported history of ADHD [attention deficit hyperactivity disorder] dx'd [diagnosed] in college. Benzodiazepines and stimulants should not be a part of his long-term treatment plan. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID [twice a day] (will keep valium PRN [as needed] available for now) Gabapentin as sedative withdrawal adjunct and seizure prevention, BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal], Plan for transition to [Facility name] PHP as soon as clinically appropriate."

Review of the physician progress note dated 9/1/2022 reads, "Interval History: Today, patient reports "unbearable headache" and "bad muscle tightness all over." Nauseated. Clenching his jaw. Feels twitchy at times. Slight tremor at times. No oversedation with medication. Has been taking PRN valium on top of the scheduled clonazepam. No SI/HI/AVH. His roommate is quite bothersome. Signs of substance withdrawal: yes, Appetite: poor, Sleep: poor. Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Sedative w/d [withdrawal] symptoms sub optimally controlled with diazepam /gabapentin. Buprenorphine has been helpful for opioid withdrawal. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID (will keep valium PRN available for now). Increase gabapentin dose today (sedative withdrawal adjunct and seizure prevention). Schedule muscle relaxer Ibuprofen for H/A [headache], BUP for OUD, Monitor Vital signs."

Review of Nursing progress note dated 9/1/2022 at 11:32 AM reads, "Pt medication compliant and up for breakfast. Withdrawn to room all morning c/o severe headache unrelieved by
Tylenol. [Medical Doctor's name] notified and 1x dose Ibuprofen 800 mg given. [Patient #1's name] reports relief. Pt also received PRN Valium for CIWA 12 after receiving Klonopin and Subutex approximately 1 hour apart. COWS 9. [Patient #1's name] thankful after being moved to private room where he will be able to rest more comfortably. [Patient #1's name] is pleasant but appears anxious with a constricted affect. Presents with a linear and logical thought process. Denies SI/SIB/HI/AVH. No morning group attended."

Review of physician progress note dated 9/2/2022 reads, "Interval History: Today, patient reports feeling "better than yesterday, better than yesterday." Sleep still not great. Negligible hand tremors. Appetite fair. Headaches continue to be annoying - relieved somewhat by the ibuprofen etc. He appreciated getting moved to a single room yesterday, as his roommate was quite bothersome. He appreciates the medication changes made yesterday. No oversedation with the current meds. Pulse and BP [blood pressure] still elevated at times. When discussing testosterone result, he admits taking a "double dose" just before coming here. Signs of substance withdrawal: yes Appetite: fair. Sleep: poor to fair. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID (will keep valium PRN available for now, today valium dose will reduce to 5 BID PRN and valium will be stopped altogether within 24). Continue gabapentin (sedative withdrawal adjunct and seizure prevention). Continue muscle relaxer methocarbamol Ibuprofen for H/A BUP for OUD Monitor Vital signs 12 Step Therapy for addiction Monitor for signs/symptoms of acute w/d, watch for oversedation Plan for transition to [Facility name] PHP when clinically appropriate. I certify that this patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel."

Review of the nursing progress note dated 9/2/2022 at 11:00 AM reads, "Patient pleasant, cooperative and medicine compliant. Patient reported "getting better" today, headache is
manageable. Patient denied SI, SIB, HI, AVH and depression. Patient endorsed having anxiety 7/10, c/o nausea - Zofran given with positive effect. CIWA 7, COWS 7, on scheduled Subutex and Clonopin [sp]. Patient given prn dose of Valium 5 mg po [by mouth] at 10:51am. Patient did not attend the morning group session. Patient interactive with some peers."

Review of the medication administration record documents that Subutex 4 mg SL (sublingual) was administered at 21:12 (9:12 PM) on 9/2/2022.

Review of the nursing progress note dated 9/3/2022 at 12:16 AM reads, "On approach, patient is resting in bed. He is pleasant and cooperative. Reports mood as "better." Denies SI/HI/AVH.
CIWA 5. COW 6. Med compliant."

Review of the nursing progress note dated 9/3/2022 at 1336 (1:36 PM) reads, "Patient found unresponsive in room this morning upon attempt to administer morning medications and assess pt. Code called and CPR [cardiopulmonary resuscitation] with AED [automated external defibrillator] initiated. 911 called. Pt unable to be revived."

Review of a physician progress note dated 9/3/2022 at 1358 (1:58 PM) reads, "Prior to our seeing the patient this morning on rounds, he was found unresponsive and code with CPR was initiated. Code was managed by psychiatry resident and by staff individual [ Doctors name]. EMS [emergency medical services] arrived on scene. Patient unable to be revived. Efforts were discontinued at approximately 10:00 a.m."

Review of the facility video for 9/2/2022 beginning at 9:17 PM with the Risk Manager showed the camera angle of the West Day room allows a view of the common area and entrance to three rooms. The entrance to two rooms, including the room of the deceased, cannot be viewed due to the presence of a large column. 9/2/2022 at 9:17:31 PM Patient #1 is observed walking, coming from around the column exiting the room. On 9/2/2022 at 9:28:32 PM Patient #1 is seen going behind the column entering the room. On 9/3/2022 at 12:12 AM a MHT is observed checking two rooms and going behind the column. Checks consisted of cracking the door open, and looking in. The MHT did not enter the observed rooms. On 9/3/2022 there was no video observing the nurse's interaction with Patient #1 at 12:16 a. m. through continuous video viewing until 1:15 AM. On 9/3/2022 at 7:37 AM MHT rises from sitting at the desk and walks out of camera frame toward the area of the assigned rooms. On 9/3/2022 at 7:38 AM the MHT reappears in the camera frame and goes behind the column, presumably to check the rooms not visible by video. On 9/3/2022 at 7:43 AM the MHT is observed chatting with the nurse from another unit. On 9/3/2022 at 7:47 AM the MHT is observed walking around the column. Breakfast trays are seen delivered to the ward. Staff are observed serving breakfast. Eight patients were seated at the table and eating breakfast. On 9/3/2022 at 8:19 AM the MHT is observed checking rooms next to Patient #1's room but did not go behind the column to check rooms. On 9/3/2022 at 9:40 AM and 19 seconds the nurse is seen going behind the column with a small cup in her hand. At 9:40 and 38 seconds, the nurse comes from around the column appearing to be in a rush and speaks to the MHT. On 9/3/2022 at 9:41 AM the Physician who was on the ward making rounds enters the room of Patient #1 and at 9:42 AM the code cart arrives. Nurses and staff are observed entering the room. Video viewing ended.

Review of the Root Cause Analysis dated 9/14/2022 reads, "34 yo [year old] was a voluntary admission seeking treatment for several years of opiate and benzodiazepine abuse, patient has had no success detoxing while at home and has had six seizures since 2019 during these attempts, patients hospital course was unremarkable (med compliant, participating in group, pleasant) until AM med pass on 9/3/2022 where he was found unresponsive in his bed. Causative Factor: Bedside hand off report does not occur between RN's and MHT's. Related Action Plan: Initiate and monitor bedside hand off report between RN's and MHT's. Causative factors: Rounding is frequently split between staff. Related Action Plan: Mandate that rounding must be limited to assigned staff only. Causative Factor: Patient was deemed asleep; therefore vitals were delayed. Related action plan: Patients must be woken up in order to refuse vital signs. Causative Factor: Q 15-minute rounding is very limited in scope. Related Action Plan: enrich the q 15-minute rounding requirements (chest rise, pen light, inside room). Causative Factor: Training for q 15-minute rounding only occurs in orientation. Related Action Plan: Institute regular q 15-minute rounding training refreshers. Causative Factor: A fully stocked crash cart with suction was not available on the unit at the time of the code. Related Action Plan: A fully stocked crash cart specific to [ Facility name] will be available on every shift. Causative Factor Staff responding to medical code were not proficient. Related Action Plan: Schedule Mock codes with Sim Lab. A plan of correction was formulated based on the root cause analysis.

On 9/21/2022 at 11:30 AM Request for training and education to the facility Risk Manager and the Facility administrator. None were provided.

During an interview on 9/21/22 at 12:50 PM the Administrator stated, "I wouldn't want to insult you by presenting what we have. It is an excel spread sheet. We do not have any formal education and training completed. We do not have any formal auditing completed. We did not change the documentation for 15-minute checks. We should have done them, but we did not do any documentation that says we did them. We did have a patient safety meeting. I was not aware that there was no code documentation. I can't say that I have thoroughly completed the training and education. We have not assigned any formal training to staff. I don't know how many staff have actually had the training. We really haven't been tracking patients to determine if they are getting 15-minute checks completed. We did not review to see if this problem affected anyone except [Patient #1's name]. I guess we should. We have not trained everyone in what our expectations for rounding are. I have done some observations of whether it was being completed, but I didn't document who I observed or what times, or the patients were observed. We should have done better than this."

During an interview on 9/21/2022 at 1:00 PM the Risk Manager stated, "We immediately began to investigate what happened and set up a RCA [root cause analysis] and talk about it, we did individual interviews, and reviewed the medical record. We determined that every 15-minute checks were not completed as documented in the record for 9/2-3/2022. After 7:47 AM there were no additional 15-minute checks completed. We also identified that there was some education for reacting to a code. The patient was not seen by staff at shift change, and routine checks were not completed. Vital signs were not completed at 6:00 AM, the quality of the checks based on the video reviewed were not consistent with our policies and procedures. We identified that the code cart was not fully equipped with suction available. We did have the systems in place, but the staff did not follow them as expected. Based on the documentation the patient was last seen at about 12:15 AM, there is documentation in the chart."

During an interview on 9/22/2022 at 9:35 AM, the Risk Manager stated, "We had two MHT's on that day. Only one that previous night. I reviewed the video. The quality of the 15-minute checks is not up to our standards. Well, they were just not, they were just looking into the rooms. Not even going into the rooms. They did not verify that the patients were breathing and not having a medical emergency. They did not verify that they were not having seizures. Our seizure precautions are not clearly defined for this area. We can't have side rails so we can't pad them. Nurses should be making sure that the MHT are doing the checks. They just can't verify that they are doing them by looking at the charting, because in this case the documentation was not correct. This was inaccurate, false documentation. There were no checks completed at 5:30, 6:00, 6:22 when the MHT documented the patient refused vitals. The tape shows that he didn't attempt vitals. The day [Staff A's name], did not attempt to complete every 15-minute checks from 7:48- 9:40 AM but documented that every 15-minute checks where completed. The nurse did not do any checks during that time. The nurses did not do bedside rounds for shift report. We should have been doing the rounds and completing them with more than opening a door and verifying the patients were in bed. We did not see this patient at all between 7:47 and 9:40 AM. It is our policy to monitor patients every 15 minutes, to verify they are okay. They should have verified the patient was breathing on the rounds. There is a nurses note that the patient had contact at 12:18 AM, there is no video to document that this occurred. The last time the patient was seen on video was the evening before." We do not have any documentation that we have provided any training or education to the staff, we do not do huddles and did not set up any training for staff related to this. We have not completed audits to determine if 15-minute checks are being completed. Without these I suppose we don't know the scope of our problem and we should know. We have not implemented our plan of correction and we should have."

During an interview conducted on 9/22/2022 at 10:30 AM, with the Interim Director of Nursing stated, "I was placed in the position after the Director of Nursing went on leave. I came into the position three days ago. I have not acted on the plan of correction. I have not done training or education with the staff. I have not completed any auditing to determine if staff are completing 15-minute checks as they should be. We have not followed the plan of correction and we should."

Review of the Policy and Procedure titled, "Patient Levels of Observation" Policy Number SPH02. 038 reads, "Policy: Patients admitted to UF Health Shands Psychiatric Hospital will be observed for patient safety. Some patients may require an increased level of observation due to the acuity of their mental illness. Purpose: to provide reasonable safety for patients and staff members and to promote a therapeutic environment. Procedures: 1. Patient observation levels at UF Health Shands Psychiatric Hospital include: A. Routine. B. One-to-one. II. All patients are minimally placed on routine observation period in the event the patient requires one to one observation, this will be communicated during handoff and in the epic unit manager." III. In the event of a significant change in a patient's condition, the RN can increase the observation level to one to one and then contact the physician for the order. IV. Only a physician can order a decrease in observation level. Routine Observation: each patient on routine observations is observed by a staff member approximately every 15 minutes."

An Immediate Jeopardy (IJ) situation was identified during the survey at A385 Nursing Services. On September 21, 2022, at 4:21 PM, the Chief Nursing Officer of UF Health Shands Hospital, an affiliated hospital, was informed of the determination of immediate jeopardy and given the immediate jeopardy template.

The immediate jeopardy began on September 3, 2022 when the facility failed to keep Patient #1 free from neglect when Patient #1 did not have every 15-minute monitoring and checks and was not assessed for vital signs per physician order to ensure patient safety according to current accepted professional standards of practice. The patient was found unresponsive and absent of vital signs. The patient did not survive.

The hospital failed to provide an adequate number of nursing personnel to safeguard the health outcomes and safety of all patients when they did not perform every 15-minute monitoring/observations and failed to assess vital signs per physician order for 1 of 3 patients reviewed for substance use disorder. This systemic failure constitutes an immediate jeopardy.

During an interview conducted on 9/22/2022 at 10:30 AM, the Interim Director of Nursing stated, "I was placed in the position after the director of nursing went on leave. I came into the position three days ago. I have not acted on the plan of correction. I have not done training or education with the staff. There were missing checks that were documented. We have not spoken to the MHT that was on that day yet. But the patient [Patient #1] was not checked every 15 minutes, the video was reviewed, and they were not completed. They should have been. There is no documentation related to the code, there should be."

UF Health Psychiatric Hospital was not in compliance with Code of Federal Regulations (CFR) 42, Part 482 Conditions of Participation for Hospitals for 42 CFR 482.23 Nursing Services.

Refer to A 0395-RN Supervision of Care

Based on video review, medical record review, interview, and policy and procedure review the facility failed to ensure nursing supervision and evaluation of patient care when the facility did not follow current accepted professional standards of practice to provide every 15-minute checks and assess vital signs per physician order for 1 of 3 patients, Patient #1. The patient was found unresponsive and absent of vital signs. Patient #1 did not survive.

Findings include:

Review of the Medical record reads, "Patient #1 was a 34-year-old male who presented to the psychiatric hospital intake voluntarily on 8/29/2022. Review of the History and physical dated 8/30/2022 reads, "CC [chief complaint]: I need help to stop using benzodiazepines and opioids. HPI [History of presenting illness]: 34 y.o. [year old] married WM [white male] from Alabama with no significant medical history presents voluntarily for medical management of benzodiazepine [a medication used for anxiety] and opioid [a class of drugs used to treat pain] withdrawal. He reports using clonazepam [a benzodiazepine used to treat seizures and anxiety] 4 milligrams per day and Xanax [a benzodiazepine used to treat anxiety and panic disorder] up to 30 milligrams per day (last use 8/28), hydrocodone [a pain medication] up to 150 milligrams per day (last use 8/25). He is also prescribed Adderall IR [a medication used to treat attention deficit hyperactivity disorder], which he uses as prescribed, 30 milligrams q.a.m. [every morning] and 20 milligrams q.p.m. [every evening] and testosterone (biweekly injections). He is made several unsuccessful attempts to discontinue the benzodiazepines and experienced at least 6 seizures after he stops taking them. He is also made several unsuccessful attempts to stop the opioids. He reports spending proximally 1000 dollars per week on substances. His wife is aware of his use and it caused conflict in his marriage. However, she is supportive in his efforts to attend treatment. He obtains Xanax and hydrocodone illicitly, although he is certain it is pharmaceutical grade. Approximate 2 months ago he attempted treatment at [Facility name] in Alabama but left after 3 days. Was on buprenorphine [a medication used to treat opiate use disorder] for approximately 2 months about 5 years ago.

Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He appears to be experiencing withdrawal symptoms, most likely related to opioids, including chills, sweating and diarrhea. Symptoms are adequately controlled with diazepam and buprenorphine. Dimension 2: Biomedical conditions and complications: None identified. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild depression/anxiety. Dimension 4: Readiness to change: The patient has both cognitive and emotional awareness of his disease. He appears to be generally internally motivated. Dimension 5: Relapse/continued use potential: He is at very high risk for continued use without treatment in a structured environment. Dimension 6: Recovery environment: He lives with his wife (who is supportive) and 3-year-old daughter. Diagnosis: Principal Problem: Sedative, hypnotic or anxiolytic use disorder, severe, dependence. Active Problems: Opioid use disorder, severe, dependence, Unspecified stimulant related disorder and Unspecified androgenic steroid related disorder. Plan: Admit to [Hospital name], Dual Disorders Unit, for inpatient detoxification/stabilization/assessment. Complete laboratory workup to include testosterone level. Obtain collateral information. Pharmacologic management of benzodiazepine and opioid withdrawal."

Review of Benzodiazepine and Opiate withdrawal symptoms include sleepless, anxiety, depression, sleep disturbance, irritability, increased tension and anxiety, panic attacks, hand tremor, sweating, difficulty in concentration, dry wrenching and nausea, some weight loss, palpitations, headache, muscular pain and stiffness and a host of perceptual changes. Instances are also reported within the high-dosage category of more serious developments such as seizures and psychotic reactions. Withdrawal from normal dosage benzodiazepine treatment can result in a number of symptomatic patterns. The most common is a short-lived "rebound" anxiety and insomnia, coming on within 1-4 days of discontinuation, depending on the half-life of the particular drug. The second pattern is the full-blown withdrawal syndrome, usually lasting 10-14 days; finally, a third pattern may represent the return of anxiety symptoms which then persist until some form of treatment is instituted. Withdrawal phenomena appear to be more severe following withdrawal from high doses of short-acting benzodiazepines. Patient #1 was being administered Valium 15 milligrams and Subutex 4 milligrams. Using buprenorphine (Subutex and Klonopin) together with other medications that also cause central nervous system depression (Valium) can lead to serious side effects such as respiratory distress, coma, and even death.

Review of nursing progress note dated 8/29/2022 at 9:55 PM reads, "Pt [patient] anxious, cooperative, during admission interview. Pt c/o [complain of] "brain zaps, restlessness, diarrhea, and anxiety; patient's forehead appeared moist. Valium, Imodium, and clonidine given. Pt reports that the valium and clonidine did not alleviate his symptoms. [Doctors name] notified. Pt endorses depression but denies SI/HI/AVH [suicidal ideations/homicidal ideations/audio visual hallucinations]. CIWA [Clinical Institute Withdrawal Assessment from Alcohol] 12, COWS [Clinical Opiate Withdrawal Scale] 9."

Review of nursing progress note dated 8/30/2022 at 4:39 PM reads, "[Patient #1's name] is calm, cooperative, and withdrawn to his room with the exception of meals and snacks. Upon 1:1 assessment the denies pain or any other somatic complaints. [Patient #1's name] reports poor sleep with a fair appetite and he describes his mood as "Better". Patient denies current depression and rates his anxiety level 4/10. [Patient #1's name] denies SI/HI/SIB[serious injurious behavior]/AVH. Will continue to monitor for safety as per care plan. CIWA [a 10 item scale used in the assessment and management of withdrawal symptoms] 7, COW [an 11 item scale used in the assessment of opiate withdrawal] 6." BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal].

Review of the physician progress note dated 8/31/2022 reads, "[Patient #1's name] is a 34 y.o. [year old] male admitted for problems related to benzodiazepines (reportedly uses on average Klonopin 4 mg [milligrams]/d [day] and Xanax 24 mg/d), opioids (hydrocodone, oxycodone, 10-15 pills/d), and Adderall 50 mg/d. Interval History: Today, patient reports insomnia, sweats, headache, twitching. He was tremulous on exam. He is willing to go to [Facility name] PHP [partial hospitalization program] after this. Signs of substance withdrawal: yes, Appetite: fair, Sleep: poor. Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Overall, symptoms have been adequately controlled with diazepam/gabapentin for sedative withdrawal, and buprenorphine for opioid withdrawal. Dimension 3: Emotional/behavioral/cognitive conditions and complications: Mild anxiety of a generalized nature, and purported history of ADHD [attention deficit hyperactivity disorder] dx'd [diagnosed] in college. Benzodiazepines and stimulants should not be a part of his long-term treatment plan. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID [twice a day] (will keep valium PRN [as needed] available for now) Gabapentin as sedative withdrawal adjunct and seizure prevention, BUP [buprenorphine] for OUD [opiate use disorder], no more testosterone, monitor Vital signs, 12 Step Therapy for addiction, monitor for signs/symptoms of acute w/d [withdrawal], Plan for transition to [Facility name] PHP as soon as clinically appropriate."

Review of the physician progress note dated 9/1/2022 reads, "Interval History: Today, patient reports "unbearable headache" and "bad muscle tightness all over." Nauseated. Clenching his jaw. Feels twitchy at times. Slight tremor at times. No oversedation with medication. Has been taking PRN valium on top of the scheduled clonazepam. No SI/HI/AVH. His roommate is quite bothersome. Signs of substance withdrawal: yes, Appetite: poor, Sleep: poor. Medical Decision-Making: Dimension 1: Intoxication and/or withdrawal potential: Does not appear acutely intoxicated. He presented with significant withdrawal potential from benzodiazepines and opioids. Sedative w/d [withdrawal] symptoms sub optimally controlled with diazepam /gabapentin. Buprenorphine has been helpful for opioid withdrawal. Plan: Continue inpatient level of care. Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID (will keep valium PRN available for now). Increase gabapentin dose today (sedative withdrawal adjunct and seizure prevention). Schedule muscle relaxer Ibuprofen for H/A [headache], BUP for OUD, Monitor Vital signs."

Review of Nursing progress note dated 9/1/2022 at 11:32 AM reads, "Pt medication compliant and up for breakfast. Withdrawn to room all morning c/o severe headache unrelieved by
Tylenol. [Medical Doctor's name] notified and 1x dose Ibuprofen 800 mg given. [Patient #1's name] reports relief. Pt also received PRN Valium for CIWA 12 after receiving Klonopin and Subutex approximately 1 hour apart. COWS 9. [Patient #1's name] thankful after being moved to private room where he will be able to rest more comfortably. [Patient #1's name] is pleasant but appears anxious with a constricted affect. Presents with a linear and logical thought process. Denies SI/SIB/HI/AVH. No morning group attended."

Review of physician progress note dated 9/2/2022 reads, "Interval History: Today, patient reports feeling "better than yesterday, better than yesterday." Sleep still not great. Negligible hand tremors. Appetite fair. Headaches continue to be annoying - relieved somewhat by the ibuprofen etc. He appreciated getting moved to a single room yesterday, as his roommate was quite bothersome. He appreciates the medication changes made yesterday. No oversedation with the current meds. Pulse and BP [blood pressure] still elevated at times. When discussing testosterone result, he admits taking a "double dose" just before coming here. Signs of substance withdrawal: yes Appetite: fair. Sleep: poor to fair. Plan: Continue inpatient level of care.Medication management, with informed consent obtained: Sedative taper for acute withdrawal management - given extreme doses taken at home, will start Klonopin taper at 4 mg BID (will keep valium PRN available for now, today valium dose will reduce to 5 BID PRN and valium will be stopped altogether within 24). Continue gabapentin (sedative withdrawal adjunct and seizure prevention). Continue muscle relaxer methocarbamol Ibuprofen for H/A BUP for OUD Monitor Vital signs 12 Step Therapy for addiction Monitor for signs/symptoms of acute w/d, watch for oversedation Plan for transition to [Facility name] PHP when clinically appropriate. I certify that this patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel."

Review of the nursing progress note dated 9/2/2022 at 11:00 AM reads, "Patient pleasant, cooperative and medicine compliant. Patient reported "getting better" today, headache is
manageable. Patient denied SI, SIB, HI, AVH and depression. Patient endorsed having anxiety 7/10, c/o nausea - Zofran given with positive effect. CIWA 7, COWS 7, on scheduled Subutex and Clonopin [sp]. Patient given prn dose of Valium 5 mg po [by mouth] at 10:51am. Patient did not attend the morning group session. Patient interactive with some peers."

Review of the medication administration record documents that Subutex 4 mg SL (sublingual) was administered at 21:12 (9:12 PM) on 9/2/2022.

Review of the nursing progress note dated 9/3/2022 at 12:16 AM reads, "On approach, patient is resting in bed. He is pleasant and cooperative. Reports mood as "better." Denies SI/HI/AVH.
CIWA 5. COW 6. Med compliant."

Review of the nursing progress note dated 9/3/2022 at 1336 (1:36 PM) reads, "Patient found unresponsive in room this morning upon attempt to administer morning medications and assess pt. Code called and CPR [cardiopulmonary resuscitation] with AED [automated external defibrillator] initiated. 911 called. Pt unable to be revived."

Review of a physician progress note dated 9/3/2022 at 1358 (1:58 PM) reads, "Prior to our seeing the patient this morning on rounds, he was found unresponsive and code with CPR was initiated. Code was managed by psychiatry resident and by staff individual [ Doctors name]. EMS [emergency medical services] arrived on scene. Patient unable to be revived. Efforts were discontinued at approximately 10:00 a.m."

Review of the medical record, there was no code blue documentation within the medical record.

Review of the facility video for 9/2/2022 beginning at 9:17 PM with the Risk Manager showed the camera angle of the West Day room allows a view of the common area and entrance to three rooms. The entrance to two rooms, including the room of the deceased, cannot be viewed due to the presence of a large column. 9/2/2022 at 9:17:31 PM Patient #1 is observed walking, coming from around the column exiting the room. On 9/2/2022 at 9:28:32 PM Patient #1 is seen going behind the column entering the room. On 9/3/2022 at 12:12 AM a MHT is observed checking two rooms and going behind the column. Checks consisted of cracking the door open, and looking in. The MHT did not enter the observed rooms. On 9/3/2022 there was no video observing the nurse's interaction with Patient #1 at 12:16 a. m. through continuous video viewing until 1:15 AM. On 9/3/2022 at 7:37 AM MHT rises from sitting at the desk and walks out of camera frame toward the area of the assigned rooms. On 9/3/2022 at 7:38 AM the MHT reappears in the camera frame and goes behind the column, presumably to check the rooms not visible by video. On 9/3/2022 at 7:43 AM the MHT is observed chatting with the nurse from another unit. On 9/3/2022 at 7:47 AM the MHT is observed walking around the column. Breakfast trays are seen delivered to the ward. Staff are observed serving breakfast. Eight patients were seated at the table and eating breakfast. On 9/3/2022 at 8:19 AM the MHT is observed checking rooms next to Patient #1's room but did not go behind the column to check rooms. On 9/3/2022 at 9:40 AM and 19 seconds the nurse is seen going behind the column with a small cup in her hand. At 9:40 and 38 seconds, the nurse comes from around the column appearing to be in a rush and speaks to the MHT. On 9/3/2022 at 9:41 AM the Physician who was on the ward making rounds enters the room of Patient #1 and at 9:42 AM the code cart arrives. Nurses and staff are observed entering the room. Video viewing ended.

During an interview on 9/21/2022 at 1:00 PM the Risk Manager stated, "We immediately began to investigate what happened and set up a RCA [root cause analysis] and talk about it, we did individual interviews, and reviewed the medical record. We determined that every 15-minute checks were not completed as documented in the record for 9/2-3/2022. After 7:47 AM there were no additional 15-minute checks completed. We also identified that there was some education for reacting to a code. The patient was not seen by staff at shift change, and routine checks were not completed. Vital signs were not completed at 6:00 AM, the quality of the checks based on the video reviewed were not consistent with our policies and procedures. We identified that the code cart was not fully equipped with suction available. We did have the systems in place, but the staff did not follow them as expected. Based on the documentation the patient was last seen at about 12:15 AM, there is documentation in the chart."

During a telephone interview on 9/21/2022 at 6:10 PM Staff A, Mental Health Technician (MHT) stated, "I was on the day that he died [Patient #1]. I did not see him at all that day. I saw him in bed when I told him that breakfast was ready, on the unit. I really thought that I did his hourly rounding. I was just confused about what I was supposed to do and what the other tech was supposed to do. I did not do any bedside report we don't do that. I have not talked to anyone, not that day or since. I did not do bedside rounds, when I saw patients, it was from the doorway. I should have gone into the room."

During an interview on 9/22/2022 at 6:35 AM Staff B, Registered Nurse (RN) stated, "I did take care of him [Patient #1] overnight before he died. The last time I saw him and spoke with him was about 12:15 AM and I saw him once more at about 3:30 in the morning, I think. He was in bed laying on his left side and snoring. So, during my initial contact with the patient [Patient #1] he was ambulatory, he said his mood was better, he looked better, was articulate, looked neat and I didn't see any withdrawal symptoms. I was not at all concerned, and the patient did not express concerns. I did not do any 15-minute checks and I don't have any responsibility to round on the patients hourly or every two hours. I did not do bedside report with the nurse that came on shift. We don't do that with our patients, we never have. I guess we should check on them together, but sleep can be a problem for our patients, they don't sleep very well so if they were asleep, I wouldn't wake them up. I don't go behind the techs to see if they are doing their work, but I am supposed to see that the checks are documented. I check that they have documented them like they should."

During an interview on 9/22/2022 at 7:00 AM Staff C, RN stated, "The role of the MHT is to do every 15-minute checks, that has always included checking respirations. The MHT on that day is not someone that I felt I needed to watch or monitor. We are not required to complete rounding on the patients hourly or every two hours. We do a patient assessment, and if they come up to us complaining of withdrawal symptoms. Seizure precautions mean they are at risk for developing seizures because of history or what they are detoxing from. I was going into his room to give morning meds. I found him on his left side, looked like he was sleeping. When I walked in the room, he was purple, stiff, and cool to touch. I hurried to the nurses' station when I found him and immediately called the code and began that process. I actually never went back into the room again; I called the code and 911. Two other nurses responded to the room and administered CPR and got the code cart."

During an interview on 9/22/2022 at 9:30 AM Staff D, RN stated, "His nurse was [Nurse's name], she went into the room and when she came out, she quietly said, "he is blue." She called the code and when I went into the room, I saw he was blue, he looked swollen, his mouth was disfigured, like his teeth were clenched, he was blue and cold to the touch. I ran and got the cart, and I called Code blue. [Medical Doctor's name] pulled him onto the floor, and we began CPR. But we could not get him back, but I think he had been dead for a while."

During an interview on 9/22/2022 at 9:35 AM, the Risk Manager stated, "We had two MHT's on that day. Only one that previous night. I reviewed the video. The quality of the 15-minute checks is not up to our standards. Well, they were just not, they were just looking into the rooms. Not even going into the rooms. They did not verify that the patients were breathing and not having a medical emergency. They did not verify that they were not having seizures. Our seizure precautions are not clearly defined for this area. We can't have side rails so we can't pad them. Nurses should be making sure that the MHT are doing the checks. They just can't verify that they are doing them by looking at the charting, because in this case the documentation was not correct. This was inaccurate, false documentation. There were no checks completed at 5:30, 6:00, 6:22 when the MHT documented the patient refused vitals. The tape shows that he didn't attempt vitals. The day [Staff A's name], did not attempt to complete every 15-minute checks from 7:48- 9:40 AM but documented that every 15-minute checks where completed. The nurse did not do any checks during that time. The nurses did not do bedside rounds for shift report. We should have been doing the rounds and completing them with more than opening a door and verifying the patients were in bed. We did not see this patient at all between 7:47 and 9:40 AM. It is our policy to monitor patients every 15 minutes, to verify they are okay. They should have verified the patient was breathing on the rounds. There is a nurses note that the patient had contact at 12:18 AM, there is no video to document that this occurred. The last time the patient was seen on video was the evening before."

During an interview conducted on 9/22/2022 at 10:30 AM, the Interim Director of Nursing stated, "I was placed in the position after the director of nursing went on leave. I came into the position three days ago. I have not acted on the plan of correction. I have not done training or education with the staff. There were missing checks that were documented. We have not spoken to the MHT that was on that day yet. But the patient [Patient #1] was not checked every 15 minutes, the video was reviewed, and they were not completed. They should have been. There is no documentation related to the code, there should be."

Review of the Policy and Procedure titled, "Patient Levels of Observation" Policy Number SPH02. 038 reads, "Policy: Patients admitted to UF Health Shands Psychiatric Hospital will be observed for patient safety. Some patients may require an increased level of observation due to the acuity of their mental illness. Purpose: to provide reasonable safety for patients and staff members and to promote a therapeutic environment. Procedures: 1. Patient observation levels at UF Health Shands Psychiatric Hospital include: A. Routine. B. One-to-one. II. All patients are minimally placed on routine observation period in the event the patient requires one to one observation, this will be communicated during handoff and in the epic unit manager." III. In the event of a significant change in a patient's condition, the RN can increase the observation level to one to one and then contact the physician for the order. IV. Only a physician can order a decrease in observation level. Routine Observation: each patient on routine observations is observed by a staff member approximately every 15 minutes."